Medical Surgical Nursing Prelims 2022-2023 PDF

MEDICAL COLLEGES OF NORTHERN PHILIPPINES NCM 118 LEC: MEDICAL SURGICAL NURSING First Semester | Academic Year 2022-2023 | Prelims Ms. Karen Joy Gaffud and Ms. Niña Anne Paracad MODULE OUTLINE...

MEDICAL COLLEGES OF NORTHERN PHILIPPINES NCM 118 LEC: MEDICAL SURGICAL NURSING First Semester | Academic Year 2022-2023 | Prelims Ms. Karen Joy Gaffud and Ms. Niña Anne Paracad MODULE OUTLINE  Vital signs such as the heart rate, blood pressure, breathing rate, and Oxygen level A. Preliminary Period are to be monitored during the procedure.  Respiratory Disorders  The patient may receive supplemental Oxygen as needed.  Diagnostic Exams  Observe the client for signs of distress, such as Dyspnea, Pallor, and Coughing.  Pulmonary Failure  Place the patient in a sitting position with arms raised and resting on an overbed  Acute Respiratory Distress Syndrome table.  Chest Injuries or Pleural Effusions  If the patient is unable to sit, the patient may be placed in a side-lying position  SARS and COVID-19 on the edge of the bed on unaffected side.  Cardiovascular Disorders  The skin at the puncture site will be cleansed with an antiseptic solution.  Diagnostics  Place a small sterile dressing over the site of the puncture.  Heart Failure  Aortic Aneurysm After the Procedure  Therapeutic Management  Observe changes in the client’s cough, sputum, respiratory depth, and breath sounds, and note complaints of chest pain.  Position the patient in a side-lying position with the unaffected side down for an hour or longer. PRELIMINARY PERIOD  Include date and time performed, the primary care provider’s name, the amount, DIAGNOSTIC EXAMS FOR RESPIRATORY DISORDERS color, and clarity of fluid drained, and all the nursing assessments and interventions provided. Thoracentesis  Transport the specimens to the laboratory. It is also known as Pleural Fluid Analysis.  The dressing over the puncture site will be monitored for bleeding or other drainage. It is a procedure in which a needle is inserted through the back of the chest wall  Monitor patient’s blood pressure, pulse, and breathing until stable. into the pleural space to remove fluid or air.  Document all relevant information. This may be performed for diagnostic or therapeutic reasons. Arterial Blood Gas Analysis (ABG) Procedure It is an essential part for diagnosing and managing the patient’s oxygenation status,  Position patient in the sitting position with arms and head resting supported on a ventilation status, and acid-base balance. bedside adjustable table.  The usual site for insertion of the thoracentesis needle is the posterolateral aspect Blood Sample of the back mid-axillary over the diaphragm, but under the fluid level.  It is drawn from the Arteries.  Sterile technique should be used including gloves, Betadine preparation and  Radial. drapes.  Brachial.  Anesthetize the skin over the insertion site with 1% Lidocaine using the 5 cc syringe  Femoral. with 25- or 27-gauge needle.  Use a hemostat to measure the same depth on the thoracentesis needle or Purpose Angiocath as the first needle.  To determine the presence and type of acid-base balance.  While exerting steady pressure on the patient’s back with the non-dominant  To check for severe breathing problem and lung diseases. hand, use a hemostat to measure the 15- to 18-gauge thoracentesis needle to  Assessment of the response to the therapeutic intervention such as mechanical the same depth as the first needle. ventilator.  While exerting steady pressure on the patient’s back with the non-dominant hand, insert the needle through the anesthetized area with the thoracentesis Normal Values in ABG Analysis needle.  pH  Attach the 3-way stopcock and tubing, and aspirate the amount needed.  It is 7.35 to 7.45.  Turn the stopcock and evacuate the fluid through the tubing.  CO2  Remove the necessary amount of pleural fluid – usually 100 mL for diagnostic  It is 35 to 45. studies – but generally not remove more than 1000 mL of fluid at any one time  pO2 because of increased risk of pleural edema or hypotension.  It is 80 to 100.  HCO3 Before the Procedure  It is 22 to 26.  Check the doctor’s order.  O2 Sat  Identify the client and explain the procedure.  It is 95% to 100%.  Ask patient to sign a consent form that gives your permission to do the test.  Inform the client not to cough while the needle is inserted in order to avoid Acid-Base Mnemonic puncturing the lung.  Respiratory – Opposite  The patient may have a diagnostic procedure, such as a Chest X-ray, Chest  Alkalosis =  pH,  PCO2. Fluoroscopy, Ultrasound, or CT Scan, performed prior to the procedure to assist  Acidosis =  pH,  PCO2. the physician in identifying the specific location of the fluid in the chest that is to be  Metabolic – Equal removed.  Alkalosis =  pH,  HCO3.  The patient may receive a sedative prior to the procedure to help the patient relax.  Acidosis =  pH,  HCO3.  Asked the patient to remove any clothing, jewelry, or other objects that may interfere with the procedure. Equipment Needed  The area around the puncture site may be shaved.  A clean-tray containing gloves.  Vital signs such as the heart rate, blood pressure, breathing rate, and Oxygen level  Antiseptic solution. are to be monitored before the procedure.  Local anesthesia.  0.5 mL Sodium Heparin (1:1000). During the Procedure  2 to 3 mL syringe with 20-, 23-, or 25-gauze needle.  Paper bag.  Need to decrease systemic or myocardial Oxygen consumption.  Use of hyperventilation to reduce intracranial pressure. Allen’s Test  Ventilation Abnormalities This is done to assess the Arterial blood flow to the hand.  Respiratory muscle dysfunction. This test can be performed for either the Ulnar or Radial artery.  Respiratory muscle fatigue.  Chest wall abnormalities. Procedure  Neuromuscular diseases.  Patient clenches fist.  Oxygenation Abnormalities  Apply firm pressure to Radial and Ulnar Arteries.  Refractory hypoxemia.  Patient relaxes hand.  Need for positive end expiratory pressure.  Release pressure on the Ulnar artery.  Excessive work of breathing.  Palm should flush within 5- to 10-second. Mode of Ventilation Sample Collection  Spontaneous  Wash hands and wear gloves.  The machine is not giving pressure breath.  Place pillow under the patient’s wrist.  The patient breath spontaneously.  Palpate the artery, either in Radial, Brachial, or Femoral to be punctured.  The patient needs only specific FiO2 to maintain its normal blood gases.  Obliterate both Radial and Ulnar Arteries at wrist by pressing them with both  Controlled thumbs.  The machine controls the patient ventilation according to set tidal volume and  Ask the patient to clench and unclench the fist until blanching of skin occurs. respiratory rate, and spontaneous respiratory effort of patient is locked out.  Release the pressure on the Ulnar artery by removing the thumb on it.  This is applicable to patient who receives sedation and paralyzing drugs.  Watch for return of circulation to skin within 15-second.  SIMV  Palpate the radial artery for pulsation.  Machine allows the patient to breath spontaneously while providing preset  Puncture the artery at 45 to 60 angle. FiO2, and a number of ventilator breaths to ensure adequate ventilation without  The Arterial blood rushes into the syringe with a great force. fatigue.  We should withdraw 2 to 3 mL of blood for sample.  Assist or Control  Once the sample has been taken, withdraw the needle and apply firm pressure  The patient triggers the machine with negative inspiratory effort. over the site of puncture with dry sponge.  If the patient fails to breath, the machine will deliver a controlled breath at a  Remove the air bubble from syringe and needle. minimum rate and volume already set.  Capping the needle.  Place the capped syringe into an ice container. Adjustment on the Ventilator  Maintain firm pressure on puncture site for 5-minute.  The ventilator is adjusted so that the patient is comfortable and in-sync with the  If patient is on anticoagulants use the high pressure dressing. machine.  Minimal alteration of the normal cardiovascular and pulmonary dynamics is desired. Follow-Up  If the volume of ventilator is adjusted appropriately, the patient arterial blood  Send the collected sample to the laboratory, immediately. level will be satisfactory and there will be no or little cardiovascular  Assess for cold hands or numbness. compromise.  Change the ventilator settings. Recommended Guideline to Follow in Using a Ventilator Complication  Set the machine to deliver the required tidal volume which is 6 to 8 mL/kg.  Bleeding.  Adjust the machine to deliver the lowest concentration of the Oxygen to maintain  Infection at puncture site. normal PaO2 which is 80 to 100 mmHg.  Blood accumulating under skin.  The setting may be set high and gradually reduced based on the ABG result.  Local pain.  Record peak inspiratory pressure.  Thrombus in artery.  Set mode to either assist or control, or SIMV, and rate according to physician order.  Feeling faint.  If the patient is on assist or control mode, adjust sensitivity so that the patient can  Numbness of hand. trigger the ventilator with the minimum effort which is usually 2 mmHg negative inspiratory force. Pulmonary Angiography  Record minute volume and measure Carbon Dioxide partial pressure PaCO 2 pH It is an X-ray of the blood vessels that supply the lungs. after 20-minute of mechanical ventilation. It is used to find a blood clot, also called a Pulmonary Embolism, in these blood  Adjust FiO2 and rate according to results of ABG to provide normal values or those vessels or to investigate any Thrombo-Embolic Diseases of the lung. set by the physician. It involves rapid injection of radio-opaque agent into the vasculature of lungs to  Incase of sudden onset of confusion, agitation, or unexplained bucking the study the pulmonary vessels. ventilator, the patient should be assessed for hypoxemia and manually ventilated A catheter is inserted into the Brachial or femoral artery, threaded into the on 100% Oxygen with resuscitation bag or AMBU bag which includes the bag, pulmonary artery, and dye is injected. valve, and mask. ECG leads are applied to the chest for cardiac monitoring. Images of the lungs are taken. Sedative and Neuromuscular Blocking Agent  Pancuornium Bromide or Pavulon. Nursing Intervention  Midazolam.  Informed consent needs to be taken before the procedure.  Neuromuscular blocking agents block the transmission of nerve impulses and  Assess history of sensitivity to sea foods or Iodine, needs to be taken. result in muscle paralysis.  Renal function test is done before contrast administration. Complication  Coagulation profile of the patient is checked before and after the procedure.  Monitor injection site and pulses distal to the site after the test.  Decreased cardiac output.  Barotrauma. Mechanical Ventilator  Nosocomial pneumonia. It is a machine that generates a controlled flow of gas into a patient’s airways. Decreased Cardiac Output Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired Oxygen tension or FiO2,  Cause accumulated in a receptacle within the machine, and delivered to the patient using  Venous return to the right atrium impeded by the dramatically increased one of many available modes of ventilations. intrathoracic pressures during inspiration from positive pressure ventilation.  Also reduced sympatho-adrenal stimulation leading to a decrease in Indication peripheral vascular resistance and reduced blood pressure.  Need for sedation or neuromuscular blockage.  Symptoms   Increased heart rate.  Rapid electrolyte changes.  Decreased blood pressure and perfusion to vital organs.  Severe alkalosis.  Decrease in the Central Venous Pressure or CVP.  Hypotension secondary to change in cardiac output.  Cool clammy skin.  Monitor for signs of respiratory distress.  Treatment  Restleness.  Aimed at increasing preload such as fluid administration, and decreasing the  Apprehension. airway pressures exerted during mechanical ventilation by decreasing  Irritability and increase heart rate. inspiratory flow rates and tidal volume, or using other methods to decrease  Assess for signs and symptoms of Barotrauma or rupture of lungs. airway pressures such as different modes of ventilation.  Increasing dyspnea.  Agitation. Barotrauma  Decrease or absent breath sounds.  Cause  Tracheal deviation away from affected side.  Damage to pulmonary system due to alveolar rupture from excessive airway  Decreasing PaO2 level. pressures and overdistention of alveoli.  Assess for cardiovascular depression.  Symptoms  Hypotension.  May result in Pneumothorax, Pneumomediastinum, and Subcutaneous  Tachycardia and bradycardia. Emphysema.  Dysrhythmias.  Treatment  Aimed at reducing tidal volume, cautious use of Positive End – Expiratory Prevent Infection Pressure or PEEP, and avoidance of high airway pressures resulting in  Maintain sterile technique when suctioning. development of auto-PEEP in high risk patients such as those with obstructive  Monitor color, amount, and consistency of sputum. lung diseases like Asthma and Bronchospasm, unevenly distributed lung diseases like Lobar Pneumonia, or hyperinflated lungs like Emphysema. Provide Adequate Nutrition  Begin tube feeding as soon as it is evident, the patient will remain on the ventilator Nosocomial Pneumonia for a long time.  Cause  Weigh daily.  Invasive device in critically ill patients becomes colonized with pathological  Monitor the input and output. bacteria within 24-hour in almost all patients.  20% to 60% of these, develop this type of Pneumonia. Monitor for Gastro-Intestinal Bleeding  Treatment  Monitor bowel sounds.  Aimed at prevention.  Monitor gastric pH and hema-test gastric secretions every shift.  Avoid cross-contamination by frequent handwashing.  Decrease risk of aspiration by cuff occlusion of trachea, positioning, use of PULMONARY FAILURE small-bore of nasogastric tube.  Suction only when clinically indicated, using sterile technique. Acute Respiratory Failure  Maintain closed system setup on ventilator circuitry and avoid pooling of Sudden and life-threatening deterioration of the gas-exchange function of the lungs. condensation in the tubing. Occurs when the lungs no longer meet the body’s metabolic needs.  Ensure adequate nutrition. Occurs when insufficient Oxygen is transported to the blood or inadequate Carbon  Avoid neutralization of gastric contents with antacids and H 2 blockers. Dioxide is removed from the lungs and the client’s compensatory mechanisms fail. Other Common Potential Problems Related to Mechanical Ventilation Values  Aspiration.  PaO2 is < 50 mmHg.  Gastro-intestinal bleeding.  PaCO2 is > 50 mmHg.  Inappropriate ventilation such as respiratory alkalosis and acidosis.  Arterial pH is < 7.35.  Thick secretions.  Patient discomfort due to pulling or jarring of Endotracheal Tube or Tracheostomy. Pathophysiology  High PaO2 and low PaO2.  Anxiety and fear. Decreased Respiratory Drive  Dysrhythmias or vagal reactions during or after suctioning.   Incorrect Positive End – Expiratory Pressure or PEEP setting. Brain Injury, Sedatives, and Metabolic Disorders  Inability to tolerate ventilator mode.  Impair the Normal Response of the Brain to Normal Respiratory Stimulation Nursing Management of Ventilated Patient  Promote respiratory function. Dysfunction of the Chest Wall  Monitor for complications.   Prevent infections. Dystrophy, Musculo-Skeletal Disorders, and Peripheral Nerve Disorders Disrupt the  Provide adequate nutrition. Impulse Transmission from the Nerve to the Diaphragm  Monitor gastro-intestinal bleeding.  Abnormal Ventilation Promote Respiratory Function  Auscultate lungs frequently to assess for abnormal sounds. Dysfunction of the Lung Parenchyma  Suction as needed.   Turn and reposition every 2-hour. Pleural Effusion, Hemothorax, and Pneumothorax  Secure the Endotracheal Tube, properly.   Monitor ABG value and pulse oximetry. Obstruction Interfere Ventilation and Prevent Lung Expansion  Suction of an Artificial Airway Atelectasis  To maintain a patent airway. Clinical Manifestation  To improve gas exchange.  To obtain tracheal aspirate specimen.  Dyspnea.  To prevent effect of retained secretions.  Cyanosis.  It is important to oxygenate before and after suctioning.  Restleness.  Headache. Monitor for Complication  Altered respirations and breath sounds.  Assess for possible early complications.  Altered mentation.  Tachycardia. Release of Vasoactive Substances Such as Serotonin, Histamine, and Bradykinin  Hypertension.   Cardiac arrythmias. Bronchoconstriction, and Vascular Narrowing and Obstruction  Respiratory arrest.  Increased Alveolocapillary Membrane Permeability Nursing Intervention   Identify and treat the cause of the respiratory failure. Outward Migration of Blood Cells and Fluids in Capillaries  Administer oxygen to maintain the PaO2 level higher than 60 to 70 mmHg.   Place the patient in a Fowler’s position. Pulmonary Edema and Hypertension  Encourage deep breathing.   Administer bronchodilators as prescribed. Impairment in Gas Exchange  Prepare the client for mechanical ventilation if supplemental oxygen cannot  maintain acceptable PaO2 and PaCO2 levels. Acute Respiratory Distress Syndrome ACUTE RESPIRATORY DISTRESS SYNDROME 3 Distinct Stage or Phase  Exudative stage. Acute Respiratory Distress Syndrome  Proliferative or fibroproliferative stage. It is a sudden, progressive form of respiratory failure characterized by severe  Fibrotic stage. dyspnea, refractory hypoxemia, and diffuse bilateral infiltrates. It is the accumulation of fluid in the air sacs. Clinical Manifestation  Early Signs and Symptoms Risk Factor  Restleness.  Direct Pulmonary Trauma  Dyspnea.  Viral, bacteria or fungal pneumonia.  Low blood pressure.  Lung contusion.  Confusion.  Fat embolus.  Extreme tiredness.  Aspiration.  Change in Patient’s Behavior  Massive smoke inhalation.  Mood swing.  Inhaled toxins.  Disorientation.  Prolonged exposure to high concentration of Oxygen.  Change in level of consciousness.  Indirect Pulmonary Trauma  Pneumonia-Causing Acute Respiratory Distress Syndrome  Sepsis.  Cough.  Shock.  Fever.  Drug overdose.  Late Signs and Symptoms  Anaphylaxis.  Severe difficulty in breathing such as labored, or rapid breathing.  Idiopathic.  Shortness of breath.  Prolonged heart bypass surgery.  Tachycardia.  Multisystem trauma.  Thick frothy sputum.  Disseminated intravascular coagulation.  Metabolic acidosis.  Massive blood transfusion.  Cyanosis with blue skin, lips, and nails.  Pregnancy induced hypertension.  Abnormal breath sounds like crackles.  Increased intracranial pressure.  Decreased PaCO2 with respiratory alkalosis.  Decreased PaO2. Pathophysiology Complete History Insult Through Indirect or Direct Trauma  On physical examination, auscultation reveals abnormal breath sounds such as  wheezing and crackles. Activation of Inflammatory Cells and Mediators Such as  First Test Serotonin, Histamine, and Bradykinin  Arterial blood gas analysis or ABG.   Blood tests. Damage to Alveolar Capillary Membrane  Chest x-ray.   Bronchoscopy. Increased Permeability of Alveolar Capillary Membrane  Sputum cultures and analysis.   Other test Influx of Protein Rich Edema Fluid and Inflammatory Cells into Air Filled Space,  Chest computerized tomography scan. Dysfunction of Surfactant, and Loss of Lung Tissue  Echocardiogram. Lung Injury Intervention   Persons with this syndrome are hospitalized and require treatment in an Intensive Damaged Type II Alveolar Cell Care Unit.   No specific therapy for patients who exists with this syndrome. Decreased Surfactant Production  Supportive Measures   Supplement of Oxygen. Decreased Alveolar Compliance and Recoil  Mechanical ventilation.   Positioning Strategies Atelectasis  Turn the patient from supine to prone.   Another position is lateral rotation therapy. Hyaline Membrane Formation and Lung Compliance  Fluid therapy is also considered.  Impairment in Gas Exchange Respiratory Therapy   Primary goal of Oxygen therapy is to correct hypoxemia. Acute Respiratory Distress Syndrome  Oxygen administered by mask. Lung Injury  Oxygen administration is given to patient at lowest concentration that results in PaO2 of 60 mmHg or greater when the FiO2 exceeds 60% for more than 48-hour  that risk of Oxygen toxicity increases.  SpO2 continuously monitored.  This is accomplished by several interventions such as performing effective resuscitation while simultaneously assessing the patient, restoring chest wall Medications integrity, and re-expanding the lung.  Antibiotics.  Rib Fracture  Anti-inflammatory drugs, such as Corticosteroids.  Assist with Intercostal Nerve Block to relieve pain so coughing and deep  Diuretics. breathing may be accomplished.  Drugs to raise blood pressure.  An Intercostal Nerve Block is the injection of a local anesthetic into the area  Anti-anxiety. around the intercostal nerves to relieve pain temporarily after rib fractures,  Muscle relaxers. chest wall injury, or thoracotomy.  Inhaled drugs, like bronchodilators.  For multiple rib fractures, Epidural Anesthesia may be used.  Hemothorax Complications  Assist with Thoracentesis to aspirate blood from pleural space, if being done  Common before a chest tube insertion.  Nosocomial pneumonia.  Assist with chest tube insertion and set up drainage system for complete and  Barotrauma. continuous removal of blood and air.  Renal failure.  Auscultate lungs and monitor for relief of Dyspnea.  Other  Monitor amount of blood loss in drainage.  Oxygen toxicity.  Replace volume with intravenous fluids or blood products.  Stress ulcer.  Flail Chest  Tracheal ulceration.  Stabilize the flail portion of the chest with hands.  Blood clots leading to Deep Vein Thrombosis and Pulmonary Embolism.  Apply pressure dressing and turn the patient on injured side, or place 10 lb  Infection sandbag at site of flair.  Catheter-related infection.  Thoracic Epidural Analgesia may be used for some patients to relieve pain  Hospital-acquired pneumonia. and improve ventilation.  Sepsis.  If respiratory failure is present, prepare for immediate Endotracheal Intubation  Respiratory Infection and mechanical ventilation.  Oxygen toxicity.  To treat underlying pulmonary contusion and serve to stabilize the thoracic cage for healing of fractures, improve the alveolar ventilation, and restore  Ventilator-associated pneumonia. thoracic cage stability and intrathoracic volume by decreasing work of  Pulmonary emboli. breathing.  Kidney Problem  Prepare for Operative Stabilization of chest wall in select patients.  Acute renal failure.  Pulmonary Contusion  Endotracheal Tube Intubation Complications  Employ mechanical ventilation to keep lungs inflated.  Laryngeal ulceration.  Administer diuretics to reduce edema.  Tracheal ulceration.  Correct metabolic acidosis with intravenous Sodium Bicarbonate. CHEST INJURIES AND PLEURAL EFFUSIONS  Use the Pulmonary Artery Pressure or PAP monitoring.  Monitor for development of pneumonia. Types of Chest Injuries  Cardiac Tamponade  Rib fracture.  Assist with Pericardiocentesis to provide emergency relief and improve  Hemothorax. hemodynamic function until surgery can be undertaken.  Flail chest.  Prepare for emergency Thoracotomy to control bleeding and to repair cardiac  Pulmonary contusion. injury.  Cardiac tamponade. Additional Responsibility Clinical Manifestation  Secure and support the airway as indicated.  Respiratory  Prepare for Tracheostomy, if indicated.  Dyspnea or respiratory distress.  This helps to clear tracheobronchial tree, helps the patient breath with less effort, decreases the amount of dead airspace in the respiratory tree, and  Cough with or without hemoptysis. helps reduce paradoxical motion.  Cyanosis of mouth, face, nail beds, and mucous membranes.  When used with mechanical ventilation, provide a closed system and stabilize  Tracheal deviation. the chest.  Audible air escaping from chest wound.  Institute the Electrocardiography monitoring for early detection and treatment of  Decreased breath sounds on side of injury. cardiac dysrhythmias which is the frequent cause of death in chest trauma.  Decrease in Oxygen saturation.  Secure one or more intravenous lines for fluid replacement, and obtain blood for  Frothy secretions. baseline studies, such as hemoglobin level and hematocrit.  Cardiovascular  Monitor serial Central Venous Pressure readings to prevent hypovolemia and  Rapid or thready pulse. circulatory overload.  Decreased blood pressure.  Monitor ABG and SpO2 results to determine need for supplemental oxygen, and  Narrowed pulse pressure. mechanical ventilation.  Asymmetric blood pressure values in arms.  Maintain ongoing surveillance complications.  Distended neck veins.  Aspiration.  Muffled heart sounds.  Atelectasis.  Chest pain.  Pneumonia.  Crunching sound synchronous with heart sound.  Mediastinal or subcutaneous emphysema.  Dysrhythmias.  Respiratory failure.  Surface Finding  Obtain urinary output hourly to evaluate tissue perfusion.  Bruising.  Continue to monitor thoracic drainage to provide information about rate of blood  Abrasions. loss, whether bleeding has stopped, whether surgical intervention is necessary.  Open chest wound.  Asymmetric chest movement. Patient Education and Health Maintenance  Subcutaneous emphysema.  Instruct patient in splinting techniques.  Make sure patient is aware of importance of automobile seat belt use to reduce Management serious chest injuries caused by automobile accidents.  Objective  Teach patient to report signs of complications increasing Dyspnea, Fever, and  The goal is to restore normal cardio-respiratory function as quickly as possible. Cough. Chest Tube  Trocar Chest Tube It is a flexible plastic tube that is inserted through the side of the chest into the  It is 2 to 3 eyelets in measurement. pleural space to re-expand the lung.  Malecot Catheter  It is a latex, is self-retaining, and has four small wings at the tip. Purpose  It is used to remove air, fluid, or pus. Chest Tube Size  To establish normal negative pressure in the pleural cavity for lung expansion.  Factors to Consider  To equalize pressure on both sides of the thoracic cavity.  Size of patient.  To provide continuous suction to prevent tension pneumothorax.  Type of drainage, either the air or fluid.  Duration of drainage. Indications  Sizes  Pneumothorax  Infants and young children are 8 to 10 ft.  Accumulation of air.  Children and young adults are 16 to 20 ft.  Pleural Effusion  Most adults are 24 to 32 ft.  Accumulation of fluid.  Large adults are 36 to 40 ft.  Chylothorax  A collection of lymphatic fluid. Insertion Site  Empyema  Triangle of safety in the mid-axillary line between the 4th or 5th intercostal space.  A pyogenic infection of the pleural space.  Anterior border of latissimus dorsi.  Hemothorax  Lateral border of pectoralis major.  Accumulation of blood.  Line superior to horizontal level of nipple.  Hydrothorax  Apex below axilla.  Accumulation of serous fluid.  Midclavicular, on the 2nd intercostal space.  Thick pectoralis major which is difficult to penetrate. Types of Chest Drainage System  Scar-cosmetic.  1-bottle.  2-bottle. During the Procedure  3-bottle.  Observe or monitor patient.  Pleurovac.  Respiration.  Saturation. Function of Pleural Drainage System  Reduce patient’s anxiety.  Prepare the underwater seal.  Connect the closed system fast. Intrapleural Inspiration Pressure After the Procedure  Care of patient.  Care of wound.  Care of the Tubing  Clamps  Water seal. Lung Air and Fluid Move  Suction apparatus. Re-Expand Into Bottle  Safety.  Ambulation. Pleural  Ambulation. Space  Exercise. Becomes  Comfort. Negative Care of Patient Principles of the Chest Tube  Auscultates lungs to assess air exchange in the affected lung.  Gravity.  Place patient in fowler’s position.  Underwater seal.  Assess for the respiratory status.  Suction.  Vital signs are taken 15-minute, 1-hour, 30-minute and 1-hour, 1-hour and 4- hour. Nursing Responsibility  Respiration rate, pattern, and rhythm.  Pre-Procedure  Color, chest pain, and rapid pulse.  Confirm the procedure.  Check saturation.  Inform patient.  Administer oxygen when necessary.  Check for the consent.  Auscultate the patient.  Prepare the equipments.  Every 2-hour.  X-ray with report to determine the affected lung.  Listen for breath sound.  Position patient.  Listen for increased area of absent breath sound.  Place patient in fowler or high fowler. Position  Supine, slightly rotated with arm on side of lesion behind patient’s head to expose Care of the Wound the axillary area.  Change the gauze when necessary.  Sit upright leaning over an adjacent table with a pillow.  Strict aseptic technique when performing dressing.  Lateral decubitus position.  Check skin integrity.  Redness. Chest Tube  Swelling.  It should be 20 inch long, 4 to 6 eyelets, and radio opaque.  Loose suture. Three Types of Tubes Care of the Tubing  Thoracotomy Chest Tube  Intact and taped.  Straight, right-angled silicon, or PVC.  Maintain patency.   Check for obstruction.  Administer analgesic in the first 24-hour.  Teach patient on how to take care of the tubing.  Allow position that comfortable to the patient.  Place a pillow between patient and tubing.  Assist patient in daily living activity.  Call the tube.  Hygiene.  Avoid dependent loop.  Instruct patient to cough if tube is blocked. Removal of Chest Tube  Milking and stripping of the tube when blocked.  Assessment.  X-ray done to check the progress. Clamps  Clamp for 2-hour.  Use rubber tips.  Chest tube removed.  Clamped at the bedside.  Clamping. Emergency Care  During transfer.  Bleeding  Not more that 1-minute.  Observe wound dressing.  Clamping chest tube will accumulate in the pleural cavity since the air has no  Observe drainage. means at escape.  Dislodgement  This can rapidly lead to tension Pneumothorax.  From insertion site, place a gauze immediately.  From connection, clamp chest tube immediately. Water Seal  Enhances flow from high to low. SARS AND COVID-19  Place below patient’s chest wall (Gravity).  Fill with sterile water. Overview  Rod must be immersed 2 cm in water.  Last December 2019 an outbreak started in Wuhan, China.  Observe for the fluctuation of water level.  Virus was identified as Corona Virus (CoV).  Fluctuation  It was Zoonotic or animal to human transmission.  To ensure the patency of the system.  Common in bats and horseshoe bats that were being sold in Wuhan Market.  It will stop when the lung fully expanded and when there is an obstruction.  The seafood market where the outbreak started sells seafood, but also  Check for obstruction by tubing-kinked, patient’s position, and ask the patient chickens, bats, civet cats, marmots, snakes and other wild game animals. to take deep breath and cough.  It is believed the virus was initially zoonotic.  Bubbling  Meaning animal to human transmission caused the outbreak by spreading the  Intermittent bubbling is normal. virus from some group of animals to people.  Continuous bubbling is abnormal.  Coronaviruses are very common in bats and horseshoe bats were being sold  Check for wound, tube, and connection. in market.  If rapid bubbling occurs without air leak, inform the doctor immediately.  Bats can spread viruses to other animals and infected animals are not likely to  Drainage Output show symptoms of being infected.  70 to 100 mL per hour.  Contact with the animal and its secretions bodily fluids could pass the virus to  Observe for any change in drainage color. people.  Mark the amount.  While not initially detected, person to person transmission has since been proven and is responsible for most/all of the cases after the initial transmission  Document input and output chart. event.  Change bottle every 24-hours or when full. COVID-19 Suction Apparatus Disease is caused by a novel coronavirus called SARS-COV-2.  Low Suction Pump The virus is mainly transmitted from person to person via droplets, contact, and  Must be controlled. fomites.  Suction valve or meter is inserted for wall suction. It is transmitted when an infected person or individual coughs, sneezes, or exhales  Check for bubbling. producing droplets of saliva containing the virus.  If no bubbling, clamp chest tube to check for air leaks and check tubing and It primarily affects the lungs but can also affect other organs. connection.  Observe patient condition while chest tube is clamped. Symptoms  People with COVID-19 have had a wide range of symptoms reported, ranging from Safety mild symptoms to severe illness.  Tube  Symptoms may appear 2- to 14-day after exposure to the virus.  Prevent kinking.  Fever.  Place a pillow as a barrier.  Cough.  Never clamp unnecessarily.  Sore throat.  Bottle  Shortness of breath.  Must be below chest.  Fatigue.  Keep bottle in basin.  Headache or muscle aches.  Inform relatives and housekeeping.  Sudden loss of taste and smell.  Runny or stuffy nose. Ambulation  Nausea, vomiting, or diarrhea.  Encourage patient to change position to promote drainage.  No need to clamp the tube. Presenting Symptoms  Maintain chest tube below chest wall.  Incubation period 14-day. Exercise Symptoms Percentage  Encourage deep breathing and arm exercise. Fever with a result of 101 F or > 38.0 C. 83%  On the first post operative day. Dry cough. 82%  When patient not in severe pain. Shortness of breath. 31%  Assist patient. Muscle ache. 11%  To enhance the lung expansion. Confusion. 9%  Prevent stiffness of the arm. Diarrhea. 8% Comfort Symptoms and Disease Course  Week 1  2 ice packs.  Persistent or intermittent fever, 77% to 98%.  2 to 3 mL vials of Viral Transport Media or VTM.  Dry cough, 46% to 82%.  Fatigue or malaise, 11% to 52%.  2 nasopharyngeal swabs.  Dyspnea, 3% to 31%.  The swabs cannot be of cotton or wooden shaft.  Sputum, 33%.  Only synthetic fiber swabs with plastic or aluminum shafts.  Myalgia, 15%.  1 zip-close bio-hazard bag.  Headache, 13%.  1 95 kPA bags.  Sore throat, 14%.  2 coronavirus disease 2019 testing approval forms.  Diarrhea, 4%. How to Collect  Nausea or vomiting, 5%.  Nasal congestion, 4%.  Nasopharyngeal and oropharyngeal swabs, as separate swabs.  Hemoptysis, 1%.  If you don’t collect a good sample, it’s a waste of an expensive test and falsely  Week 2 negative.  Day 6 to 9 of symptoms.  Collect sputum only if patient has productive cough, do not induce cough.  15% to 20% develop severe dyspnea due to viral pneumonia.  Bronchoalveolar lavage is also high risk to healthcare workers.  Hospitalization, supportive care and oxygen.  Week 2 to 3  If intubated, collect tracheal aspirate.  Of hospitalized patients, 1/3 ultimately need ICU care, with up to half needing Prevention intubation, and 5% of total diagnosed cases need ICU.  Best way to prevent the spread of COVID in the health care setting and community.  Can rapidly decline, over 12- to 24-hour from mild hypoxia to frank acute  Our hands are our main tool for work as health care workers, and they are the key respiratory distress syndrome. link in the chain of transmission.  Cytokine storm or multi-organ failure.  Late-stage sudden cardiomyopathy or viral myocarditis, and cardiac shock. Standard PPE Full PPE Enhanced PPE  Hair net.  Hair net.  Medical cap or Mode of Transmission  Goggles or eyes-  Goggles or eyes- hod.  Respiratory Droplets visors. visors.  Googles or eyes-  Exposure to sneezing and coughing. visors.  Surgical mask.  Face shield.  Close Contact or Direct Contact  Waterproof gown.  N95 mask.  Face shield.  1 meter distance, prolonged period of exposure.  Disposable gloves.  Waterproof gown.  N95 or respirator  Fomites mask.  Shoes covers.  Double disposable  Inanimate, contaminated objects.  Medical protecting gloves.  Airborne coverall.  Legs cover  Intubation, suctioning. waterproof boots.  Double disposable  Fecal or Oral gloves.  Viral shedding present in stool and diarrhea is common.  Legs cover waterproof boots. Airborne Transmission Standard endoscopy room. Negative pressure room. This refers to infectious agents being carried over long distances through the air. Airborne particles include material that has settled on surfaces and become Mask Protection Efficiency resuspended by air currents, as well as infectious particles blown from the soil by the wind. Types of Level Oo Efficacy Mask Virus Bacterial Dust Pollen Persistence of Corona Viruses on Surfaces N95. 95% 100% 100% 100%  Glass and Wood Surgical. 95% 80% 80% 80%  4-day. FFP1. 95% 80% 80% 80%  Paper Active. 10% 50% 50% 50%  4- to 5-day. Cloth. 0% 50% 50% 50%  Plastic Sponge. 0% 5% 5% 5%  5-day.  Aluminum Social Distancing  2- to 8-hour. It is staying away from crowds or congregations of 10 or more people with the intent  Surgical Gloves of minimizing transmission of infectious disease outbreaks.  8-hour. This could include but is not limited to attending concerts, sporting events, religious  Steel gatherings, going to movie theaters or using public transportation such as buses  48-hour. and subways for travel. People should maintain 6 ft of distance between each other to help mitigate the Testing spread of COVID-19.  Real-time Polymerase Chain Reaction of RNA (RT-PCR)  60% to 80% sensitive. Tips for Family and Kids  Nasal and Orophangeal swabs, collect 2 swabs.  Talk to your kids about what is social distancing and walk them around the house  Blood or urine does not detect any virus but blood could be tested for IgM and and point out fingerprints which may help them understand that each point of IgG. contact is an opportunity for transmission.  Stool does not generally used for testing.  Encourage family and friends to create a plan for their elderly relatives, parents, or  A single negative RT-PCR doesn't exclude COVID-19, especially if obtained grandparents if they’re accepting and to inform them of the high risk and concerns from a nasopharyngeal source or relatively early in the disease course. about COVID-19.  If RT-PCR is negative but suspicion remains, consider ongoing isolation and  Cancel current travel plans and trips. re-sampling several days later.  Sensitivity from private labs may vary, no data yet and also dependent on Do’s collection technique and timing such as early test on asymptomatic may not  Facetime your friends and family often. be accurate.  Keep a daily routine.  Participate in activities, but remotely, such as virtual workout classes, book clubs, Testing Kits or streaming activity options for your kids.  1 cold shipper with refrigerate and category B labels.  Continue to pay your household staff such as a housekeeper or dog walker even though they will no longer come to your house.  Consider drive through takeout, if your family is low on food supplies. Don’ts  Play dates for your children.  Meeting small groups for dinner or drinks.  Non-essential doctor’s appointments such as dental and therapies.  Hair and nail appointments.  Non-essential help around the house such as cleaning or cooking. New Classification of Individuals Old New Hindi isang person under monitoring or Hindi COVID-19 na kaso. patient under investigation. Person under monitoring. Hindi kasama sa bagong klasipikasyon. Person under investigations with mild, Suspect. sever, or critical symptoms na wala pang test o hindi pa-natest. Person under investigation with mild, Probable. sever, or critical symptoms na hindi tiyak o tukoy ang resulta ng test. Positive. Confirmed. Suspect Case A  A patient is considered under this category if there are Influenza-like illness such as fever with 38 C and presence of cough or pain in throat.  Concerns  Naglakbay o nanirahan sa isang lugar na may ulat ng local na transmisyon ng sakit na COVID-19 sa loob ng 14 na araw bago magsimula ang mga sintomas.  Nagkaroon ng close contact sa isang confirmed o probable na kaso ng COVID-19 sa loob ng 14 na araw bago nagsimula ang mga sintomas.